Great expectations: The government seeks to provide greater coverage

Thailand delivers health care effectively, fairly and at a relatively low cost. Its Universal Coverage Scheme (UCS) together with two other national programmes provide good basic benefits to all Thais, and now to most residents of the county. Because of its success Thailand is sometimes regarded as a health care model in the developing world. More broadly, the country has tackled and continues to focus successfully on public health issues. Longevity is high, infant mortally is low and the incidence of infectious disease has declined in recent decades.

At the high end of the market, Thailand competes well on the global stage. Its private hospitals are some of the best in the world and attract a steady inflow of visitors from both developing and developed countries. These institutions are upping investments and redoubling their efforts to stay on the cutting edge of medicine.

MODEL SYSTEM: Like most health care systems in the world, Thailand’s is currently under strain. The costs of delivery are increasing, while patients are expecting more. Only a few years ago the majority of citizens were happy to see a doctor and receive basic treatment for free, however, they are now demanding more advanced care. And while medical breakthroughs allow for better and more effective treatment, they also require huge outlays for the relevant equipment and medicines. Thailand is also ageing quickly, which will stress the system and require the government to commit a larger percentage of the national budget to health care.

UCS: The country’s care system traces its roots back to the late 19th century, with the founding of Siriraj Hospital in Bangkok in 1888. However, only minimal care was offered to the general public in the decades that followed. A nationwide hospital system was not completed until the 1950s, and it was not until 1975 that a health care programme for the poor was introduced by the government.

From that point forward development was rapid, with Thailand quickly catching up to and jumping ahead of some of its peers. The 1977 constitution recognised health care as a right, and mandated equal access, while the UCS was introduced in 2003 to cover people not previously in a programme or in a weak programme. The UCS was expanded in 2008 to provide more extensive coverage. All along, the system has been becoming increasingly universal. The percentage of people covered increased from 92.5% in 2002 to 99.8% in 2015.

DUELLING SYSTEMS: Thailand now has three systems running concurrently. The Civil Servants’ Medical Benefit Scheme (CSMBS) covers government employees and their dependants, while formal sector employees are enrolled in the social security scheme or the UCS, depending on time employed in the current position. Everyone else, including informal workers and the unemployed, are covered by the UCS. The CSMBS benefits package is slightly better than that offered by the other two.

The UCS is not only broad in its provision of benefits but well thought out in terms of implementation. It was introduced with significant structural reforms. Payments are made based on services performed rather than to build inputs to arbitrary levels, such as numbers of beds or doctors. This has resulted in budgeting discipline and a reduction in expenditures. Funding for the system has been boosted with a cigarette tax, which not only provides money for the treatment, but helps encourage better lifestyles. Health promotion and disease prevention have been emphasised. The country has also invested heavily in information technology to ensure the efficient use of resources and as a way to collect and analyse data received from the health care system.

Because of a long tradition of universal coverage in the country, dating back more than a decade and a half, sound implementation of the relevant programmes and continual refinement of them, infant mortality, sick days and the financial burden of medical costs in Thailand have been reduced significantly. For example, average life expectancy at birth is at 75 and infant mortality at birth is down to 13 per 100,000. Deaths due to tuberculosis have been halved since 1990.

Thailand delivers a significant amount of care for relatively little. The country spent an estimated $228 per capita on health care in 2014, far below the world average of $1060. However, that is up from $100 in 1995. Thailand spends more than Vietnam ($142) the Philippines ($135), Indonesia ($99) and Laos ($33), but less than Singapore ($2752), Malaysia ($456) and China ($420). In 2014 Thailand committed about 4.1% of GDP on health care, less than the 9.9% world average, but up from 3.5% in 1995. Malaysia spends 4.2%, Indonesia 2.8%, Myanmar 2.3%, Laos 1.9% and Vietnam 7.1%.

ONGOING PROJECT: System development continues. In 2013 Thailand adopted the Quality and Outcomes Framework. Under this programme, which is implemented by the National Health Security Office, performance measures are utilised to drive the improvement of health care. It is a so-called pay-for-performance system, or P4P. Other measures are being taken to promote consistency over time. The national health care scheme is moving from annual budgets to two-year budget proposals.

Health care IT systems are being further developed, with the Ministry of Public Health working with VM ware, a subsidiary of Dell Technologies that provides cloud computing software, deploying the company’s vSphere and VM ware Horizon. The country has more than 10,000 health-related IT systems. The eventual goal is to integrate them to improve work flows, help with diagnoses and make care in the country more evenly distributed. The Digital Thailand initiative also touches on health care. One of its many goals is to improve access and reduce inequality in the sector.

Recently Thailand has been making efforts to become more of a medical leader rather than an implementer of existing advances. It is endeavouring to work up the health care value chain. This is especially the case in terms of clinical trials, where it has ranked well in ASEAN in past years. However, it is trailing in the region when compared to more advanced economies. Thailand conducted about 1000 such trials between 2010 and 2015, while Taiwan conducted 2000 and South Korea 4000.

EXPANDED BENEFITS: The medical programmes are being expanded both in scope and depth. Since 2013 the government has extended the right to universal health care to migrants on the same terms as locals. Migrants make up 6% of the country’s population and 5% of its workforce. Insuring them is both a practical step and one driven by human rights considerations. In April 2017 the government increased benefits for people voluntarily insured under the Social Security Act. Individuals in this category will receive up to BT300 ($8.50) for each day spent hospitalised and a BT10,000 ($281.70) one-time retirement benefit if they have been in the programme for more than 180 months. The funeral benefit will increase to BT43,000 ($1211) for people insured under the programme for more than six months. Those with children will receive BT200 ($5.60) per month per child for up to two children.

The government is also extending national coverage to include a wider range of stem cell procedures. Stem cell therapies have been a benefit under social security for two decades, but to date only those involving cells from the patient or from siblings would be covered. However, now cells from unrelated donors will be included. On top of this, the maximum age for the therapy has been increased, from 60 to 65, and more diseases will be included, while the budget for treatment will almost be doubled, from BT750,000 ($21,128) to BT1.3m ($36,622).

Most importantly, perhaps, are changes being implemented with respect to emergency care. On March 28, 2017, the Universal Coverage for Emergency Patients (UCEP) policy was approved, effective April 1, 2017. Under the programme, hospitals must provide 72 hours of emergency care to all people under one of the three health care systems. All public and private hospitals are included. To qualify, patients must be suffering from one of six symptoms, otherwise they will be transported to a government hospital. After the initial 72 hours, they will be moved if it is safe to do so. Patients will also have the option to stay at the admitting hospital and pay for additional treatment. Benefits for the first 72 hours are paid according to a fixed schedule. The scheme is administered under the newly formed National Institute for Emergency Medicine.

A similar programme had been run in the past, but it was voluntary and in some cases proved to be ineffective. In contrast, UCEP comes with strict penalties, including fines and jail time, for the failure to follow the rules and the turning away of legitimate patients. In the first eight days of the programme about half the patients were denied treatment as their conditions were not deemed to be life threatening. Some instances of rejection have been determined to have been done in error.

AMENDMENTS PROPOSED: The government has proposed amending the National Health Security Act, which was passed in 2002 and established the National Health Security Office (NHSO). The NHSO manages the finances of Thailand’s universal health care. While generally regarded as a success, sustainability of the programme has been a concern for some time. Hospitals receive a fixed payment for covering patients that come to them for free treatment, but the allocated budget is not usually enough to compensate them for the services provided. This has led to hospitals seeking to reduce the number of such patients that they take in by cutting bed numbers or by simply turning them away.

The government argues that the law needs to be changed so that the system becomes more sustainable and so that delivery of services is improved. A total of 14 major amendments have been proposed, and co-payments are on the list.

Advocates of the overhaul believe that the current system will face long-term difficulties. For the programme to survive and to be effective, the cost structure must be reevaluated and updated. They add that the quality of medical service overall in the country is suffering because of weaknesses in the programme and argue that people should pay for services to the extent they can afford to.

The move has inspired significant opposition. Critics argue that the risk is that the scheme, which now provides free services to all Thais not otherwise covered, will revert back to the old system, whereby only the destitute receive care for free. They also have concerns about proposed changes to the governance structure of the programme, saying that the amendments will put too much power into the hands of the hospitals.

NGOs allege that the process has been shrouded in secrecy and that the law is being amended without sufficient engagement with all stakeholders. They are calling for the process to be started over so that a round of inclusive discussions can be held.

BY THE NUMBERS: The ratio of doctors and nurses to total population is 2.28 per 1000 in Thailand. That is within the range recommended by the World Health Organisation (WHO). Despite the overall ratio being good, certain geographical areas in the country lack a sufficient number of health care professionals. And while the UCS has been widely praised, it nevertheless has some gaps as well.

A study supported by the Health Systems Research Institute found that vulnerable people, including the stateless, the poor and those from rural areas, did not have comprehensive access to benefits provided by the state. The expectation is that the country will have sufficient human resources in the sector in the future, as more people are being trained in medical fields while the population is declining. The number of pharmacists, however, is said to be a concern. Incentives are being recommended to attract more people to the field.

BUDGET CONCERNS: Most worrying is the financial condition of the sector. The system is under significant pressures due to constraints at the government level. While a universal health care budget of BT164bn ($4.6bn) was requested 2017, only BT151bn ($4.3bn) was allocated, with funding per person dropping from BT3745 ($95) per year to BT3100 ($87). Concern has been raised about the impact of the reduction on the level of care, and whether it will be possible for a system already under strain to do as much as before on a limited budget.

A copayment has been suggested to increase the stability of the system. However, the idea has been met with waves of criticism by those who claim that the government is trying to end the popular programme. Free treatment is now considered a right, with a copayment of BT30 ($0.85) dropped in 2006.

At some facilities, the situation is critical. An estimated 18 state hospitals in the country are now effectively bankrupt, with debts ranging from BT92m ($2.6m) to BT400m ($11.3m), while some newly trained medical professionals working in the state hospital system said in early 2017 that they have not been paid in months.

The shortage is the result in poor management and insufficient funding from the universal health care programme, according the local press. Prime Minister Prayut Chan-o-cha ordered in April 2017 that BT5bn ($140.9m) be allocated to 80 hospitals in the country facing financial difficulty. Five of the hospitals targeted are in critical condition. The money being allocated is seen as only a temporary solution. In the long term, the sector is going to have to be restructured.

However, the prime minister has made it clear that all health benefits will remain and that no programmes would be scrapped or cut. He said that comments to the contrary were just rumours and speculation, adding that the government was considering the increase of some benefits. Labour groups are still pushing for reforms. They are calling for the Social Security Office to be placed under the Ministry of Labour and would like to see the rules of the UCS programme amended so that treatment can be sought at any hospital.

The government has developed a plan to transfer the CSMBS to private insurers to reduce the burden of civil servant health care on the national accounts. Critics say that the movement of the BT70bn ($2bn) annual budget could result in a reduction of benefits and a weakening of public hospitals. Funds now used for management of the programme would go to the private sector, depriving the hospitals of a source of revenue. A total of 6m members would be affected. The suggestion by those opposing the move is to have better oversight of the budget rather than transferring responsibility to the private sector.

OLDER REALITY: Health care in the region is rapidly becoming more expensive. According to Mercer, a US-based health consultancy firm, the cost of providing coverage to employees in Asia is seen rising at five times the rate of general inflation. The consultancy stated that the increase is in part related to poor lifestyle choices made by office workers, especially their lack of exercise. Other drivers of increased health costs are technological advances and higher pay in the health care sector.

Ageing is also a factor, especially in Thailand. The National Statistical Office reported that the country will have 17m senior citizens by 2021, which will officially make Thailand an ageing society. An estimated 20% of the population will be retired by 2025. By 2040, those over 65 will make up a quarter of the population, and by 2050 that number will be 30%.

The government is working on the development of creative solutions. To tend to the needs of older people, it is establishing family care teams, comprised of doctors, nurses, dentists, pharmacists, public health officers, traditional medicine experts, physiotherapists and health care volunteers. They will be drawn from local hospitals and clinics as well as from state agencies established in the regions. An estimated 3250 teams will be in place by 2022 and 6500 by 2025. Teams are already active in Phetchabun Province. They help the people in the area with quality-of-life issues, tend to non-critical illnesses and determine whether ailments require transfer to hospital. “Thailand’s ageing population, while positive in the sense that people are living longer, will present new challenges for the domestic health care sector as demand for treatment against cardiovascular disease, diabetes and oncological disease are expected to increase,” Ivan Poljak, general manager for Takeda (Thailand), told OBG.

HEALTH ISSUES: While Thailand has done an exemplary jobs of fighting diseases, challenges remain. Drug resistant infections are on the rise in the country, according to a study by Oxford University and Mahidol University. The study said that the increase is in part the consequence of the overuse of antibiotics in people and in animals because of weak policies and the lack of regulation. Antibiotics are available over the counter in Thailand, and are often taken when there is no need for them. Also, the high number of medical tourists could result in the introduction of drug-resistant bacteria from other countries. The study reported that deaths attributable to drug-resistant infections in Thailand were almost as high as those in the US and the EU in 2010.

Given its climate and geographical location, Thailand remains vulnerable to a number of diseases, including malaria, hepatitis, rabies, cholera, Japanese encephalitis and leptospirosis. It has also been at risk of SARS, MERS and Ebola as many travellers from other countries enter its territory. The main concern in 2016 and 2017 was Zika. In the first nine months of 2016 Thailand recorded about 200 cases, with an average of 20 per week reported. The authorities added at the time that the situation was stable. However, Thailand has been pushed to increase transparency on the infection, as it has been hesitant to report cases on concern that such disclosures could affect the tourism sector.

Perhaps the greatest problem faced by Thailand in terms of health is the rise of non-communicable diseases (NCDs). With high rates of smoking, stressful lifestyles and the quality of diets in decline in the country, the percentage of people dying from NCDs has been rising in recent years. Deaths from a number of key NCD categories, including heart disease, stroke and diabetes, have increased significantly since the turn of the millennium. However, awareness has been on the increase. As more Thais have entered the middle class, society becomes better educated about the risks associated with a poor lifestyle. While the rise in incomes can lead to an increase in diabetes and cardiovascular disease, it can also result in people changing their habits.

HOSPITAL GROUPS: Before the 1997 financial crisis, the Thai health care sector was overbuilt as a result of the excessive investment committed to it. After the collapse, however, the sector contracted and the number of beds available dropped by about 10% from the peak to the recent low in 2010.

While the total numbers have been increasing again since 2010, the main focus recently has been on mergers and acquisition, investment in existing facilities and increasing efficiency. Thailand currently has 17,000 about medical facilities, with 70% of those owned by the state.

Private hospitals have been facing somewhat of a growth recession, with publicly-listed health care groups in the country cutting their forecasts. The weakness has been due to the sluggish domestic economy and lower demand from Gulf Cooperation Council (GCC) countries due to low oil prices. Bangkok Dusit Medical Services (BDMS) and Bumrungrad, two local health care groups, have both been anticipating slower growth. Competition is also a factor, with other countries in the region aggressively challenging Thailand in the medical tourism market. Overseas hospital groups, especially in the GCC region, are also providing care to locals who would once have travelled to Thailand.

However, given the underlying fundamentals, the secular trend is encouraging and the prospects for the private hospital groups are good. The growing middle class is going to demand better services and higher quality medical care. An ageing society will put more of an emphasis on the public system and drive some people towards private medicine.

While corporate activity in the sector is down somewhat from 2013 and 2014, the private sector continues to seek ways of increasing critical mass and efficiency. The Thonburi Hospital Group is planning for an initial public offering (IPO) in summer 2017, selling shares worth about 10% of its registered paid-up capital (though it has been repeatedly delayed). According to Dealstreet Asia, the funds will be used to upgrade existing hospitals and help finance a new facility: Medical City in Pathum Thani Province. The company expects to raise about BT8bn ($232m). Thonburi Hospital has been particularly aggressive, especially about expanding overseas. The group said in late 2015 that it would be investing $1bn in China. It also hopes to invest more regionally, especially in Cambodia, Laos, Vietnam and Myanmar.

In September 2016 Vibhavadi Medical Centre purchased 28.6% of Bangpo General Hospital for BT300m ($8.5m). Vibhavadi also plans to spend an estimated BT1bn ($28.2m) through 2020 to build five new hospitals in the region.

In late 2016 Paolo Hospital, a BDMS subsidiary, bought Mayo Polyclinic for approximately BT1.4bn ($39.4m). BDMS is building a luxury medical centre that will offer anti-ageing and holistic health care. The $377m project is being billed as the first holistic health care centre in Asia.

“Thailand has proven itself to be a strong investor in health care, and the private hospital segment in particular is booming, owing to both high levels of quality and competitive advantages against regional neighbours in terms of pricing,” Poljak told OBG.

OUTLOOK: Thailand has built a strong foundation in health care. It has an efficient and comprehensive public medical system and a well managed and well funded private sector. However, challenges are significant, as the country faces higher medical costs and as the sector faces increased competition.